This research brief from the Center for Studying Health System Change describes some of the challenges that physician practices face in implementing electronic prescribing, enabled by health information technology. E-prescribing may reduce medication errors, improve physician practice and pharmacy efficiency, and support care coordination by providing physicians with well-documented medication lists and pharmacists with legible and complete prescriptions. Many e-prescribing systems have features that give physicians access to difficult-to-get information from external sources that could potentially improve prescribing decisions, including patients’ medications prescribed by physicians in other practices, patient formularies and other prescription drug benefits, and generic medication alternatives.
If physicians wish to access a patient’s medication history or formulary information through the main e-prescribing intermediary vendor Surescripts, they first must initiate an eligibility request to identify a patient’s health insurer or pharmacy benefit manager (PBM). The request travels through the physician’s e-prescribing vendor to Surescripts, which in turn transmits the request to participating health insurers and PBMs and then sends back a response. To match patients between these sources, a probabilistic algorithm relies on five patient identifiers sent from the physician’s e-prescribing system, including patient first and last names, date of birth, gender and zip code. If a match is made with the health insurer/PBM data, an eligibility key is returned that can link the patient to formulary information and medication history; otherwise an error message is sent.
Upon physician request, eligibility information can then be used to match and return a patient’s medication history for up to the past two years based on adjudicated medication claims data. Participating health insurers/PBMs must provide medication name, strength, dosage form and date filled, with the option to include additional data such as prescriber, fill location, number of refills and whether or not the prescription was required to be dispensed as written. As part of the eligibility request, Surescripts requires physicians to complete an additional field indicating if patient consent to access the medication history has been obtained.
In contrast to requests for patient eligibility and medication histories, which are real-time transactions, in the case of formularies, eligibility information is used to match a patient to information on the relevant drug plan stored in formulary files, which are downloaded to the practice’s computer periodically. These files are updated anywhere from daily to quarterly by participating health insurers and PBMs and then are available through Surescripts to e-prescribing vendors. Vendors are required to make files available weekly for practices to download. The timeliness of the information displayed to the physician depends on how frequently the different parties, including the practice, refresh the information.
Health insurers and PBMs, at a minimum, indicate whether the drug selected by the physician is on formulary or not. Less commonly, additional data may be provided on copayment tiers, coverage limitations, on-formulary therapeutic alternatives and insurer/PBM requirements that physicians request prior authorization of insurance coverage before prescribing certain medications. Because these data are typically “rep- resentative” and are only provided for a subset of an insurer’s health plans, this infor- mation may not reflect the exact benefits under a patient’s specific policy.
Commercial insurer and medicaid participation in Surescripts is voluntary and not all payers provide information. In contrast, Medicare Part D plans are required to make all of the information available for e-prescriptions for Medicare Part D patients. For example, the percentage of patients with available information in 2009 ranged from 47 percent to 90 percent in the 12 states where practices in this study were located.
While most of the 24 practices studied for this research brief reported that physicians had access to patient formulary information, only slightly more than half reported physician access to patient medication histories, and many physicians did not routinely review these sources of information when making prescribing decisions. Study respondents highlighted two barriers to use: 1) tools to view and import the data into patient records were cumbersome to use in some systems; and 2) the data were not always perceived as useful enough to warrant the additional time to access and review them, particularly during time-pressed patient visits.
The research brief concludes with the following recommendations to increase the use and usefulness of e-prescribing:
- Increasing data availability and usefulness
- Enhancing system design
- Targeted physician education and training